The change of working alliance and the association to treatment outcome in an internet-based therapy after pregnancy loss.

BACKGROUND: Working alliance is a prominent non-specific factor for treatment outcomes in face-to-face and internet-based interventions. The association between working alliance and therapy outcome appears to be time- and disorder-specific, but less is known about the change of working alliance during the intervention and the impact of working alliance in grief-specific interventions. The present study examines the association between the change of working alliance and treatment outcomes in an internet-based intervention for parents who experienced pregnancy loss. METHODS: 228 participants received a grief intervention based on cognitive behavioral therapy with asynchronous text-based therapist feedback. Prolonged grief and related symptoms of traumatic stress, depression, anxiety, and general psychopathology were assessed with validated instruments before and after the intervention. The change of working alliance was assessed using the short version of the Working Alliance Inventory at mid-treatment (session 4) and the end of the treatment (session 10). RESULTS: Data for N = 146 persons was analyzed. Working alliance in total and all subscales increased significantly from sessions 4 to 10. This change in working alliance correlated significantly with a reduction in prolonged grief. Changes in subscales of working alliance also correlated with symptoms of depression and general psychopathology. Regression analysis showed that a change in working alliance predicted a reduction in prolonged grief but did not predict improvements in other grief-related symptoms. CONCLUSION: The results examine the change of working alliance during an internet-based intervention and the association with treatment outcome. A small impact of change in working alliance on treatment outcome of prolonged grief was confirmed, but not on related symptoms. Further research is needed to assess moderators of the alliance-outcome association to improve internet-based interventions. TRIAL REGISTRATION: Not applicable.

Randomized Controlled Trial of an Internet-Based Cognitive-Behavioral Treatment Program for Binge-Eating Disorder.

Binge-eating disorder (BED) is a prevalent health condition associated with obesity. Few people with BED receive appropriate treatment. Personal barriers include shame, fear of stigma, geographic distance to mental health services, and long wait-lists. The aims of this study were to examine the efficacy of an Internet-based cognitive-behavioral intervention for adults with threshold BED (DSM-IV) and to examine the stability of treatment effects over 12months. Participants were randomly assigned to a 16-week Internet-based cognitive-behavioral intervention (n=69) or a wait-list condition (n=70). Binge-eating frequency and eating disorder psychopathology were measured with the Eating Disorder Examination-Questionnaire and the Eating Disorder Examination administered over the telephone. Additionally, body weight and body mass index, depression, and anxiety were assessed before and immediately after treatment. Three-, 6-, and 12-month follow-up data were recorded in the treatment group. Immediately after the treatment the number of binge-eating episodes showed significant improvement (d=1.02, between group) in the treatment group relative to the wait-list condition. The treatment group had also significantly reduced symptoms of all eating psychopathology outcomes relative to the wait-list condition (0.82≤d≤1.11). In the treatment group significant improvement was still observed for all measures 1year after the intervention relative to pretreatment levels. The Internet-based intervention proved to be efficacious, significantly reducing the number of binge-eating episodes and eating disorder pathology long term. Low-threshold e-health interventions should be further evaluated to improve treatment access for patients suffering from BED.

[Child maltreatment in binge eating disorder: a systematic literature review]. / Kindesmisshandlung bei Binge-Eating-Störung: Ein systematischer Literaturüberblick.

OBJECTIVE: This review is to provide a first overview about prevalences and associations of forms of child maltreatment in binge eating disorder (BED). METHODS: Systematic literature search in PubMed and Web of Science in December 2013. Terms considered were "binge eating disorder" AND "child* maltreatment", "child* abuse", "child* sexual abuse", "child* emotional abuse", "child* physical abuse", "child* emotional neglect" as well as "child* physical neglect". Inclusion criteria were studies published between 1990 and 2013, publications in English or German, adult patients, studies that considered patients with full DSM criteria for BED, and studies that reported prevalences of forms of child maltreatment. RESULTS: Eight studies out of 366 met criteria. Child maltreatment rates in BED were more than two times higher than in representative samples, but they were similar to psychiatric comparisons. Up to 83 % of patients with BED reported at least one form of child maltreatment. There were associations to psychiatric comorbidity, but not to gender, obesity and specific features of the eating behaviour. CONCLUSION: Child maltreatment is very prevalent among BED. Its contribution to the development and the maintenance of BED is not understood yet.

Brief Internet-based intervention reduces posttraumatic stress and prolonged grief in parents after the loss of a child during pregnancy: a randomized controlled trial.

BACKGROUND: The loss of a child during pregnancy causes significant psychological distress for many women and their partners, and may lead to long-lasting psychiatric disorders. Internet-based interventions using exposure techniques and cognitive restructuring have proved effective for posttraumatic stress disorder (PTSD) and prolonged grief. This study compared the effects of an Internet-based intervention for parents after prenatal loss with a waiting list condition (WLC). METHODS: The Impact of Event Scale - Revised assessed symptoms of PTSD; the Inventory of Complicated Grief and the Brief Symptom Inventory assessed depression, anxiety, and general mental health. The 228 participants (92% female) were randomly allocated to a treatment group (TG; n = 115) or a WLC group (n = 113). The TG received a 5-week cognitive behavioral intervention including (1) self-confrontation, (2) cognitive restructuring, and (3) social sharing. RESULTS: The TG showed significantly reduced symptoms of posttraumatic stress, prolonged grief, depression, and anxiety relative to the WLC control group. Intention-to-treat analysis revealed treatment effects of between d = 0.84 and d = 1.02 for posttraumatic stress and prolonged grief from pre- to posttreatment time points. Further significant improvement in all symptoms of PTSD and prolonged grief was found from the posttreatment evaluation to the 12-month follow-up. The attrition rate of 14% was relatively low. CONCLUSIONS: The Internet-based intervention proved to be a feasible and cost-effective treatment, reducing symptoms of posttraumatic stress, grief, depression, anxiety, and general mental health after pregnancy loss. Low-threshold e-health interventions should be further evaluated and implemented routinely to improve psychological support after pregnancy loss.

[Working alliance in internet-based therapy for binge eating disorder]. / Die therapeutische Beziehung in einem internetbasierten Programm zur Behandlung der Binge-Eating-Störung.

OBJECTIVE: Findings about the association between working alliance and therapy outcome in Internet-based treatments are contradictory. Evidence for the working alliance in Internet-based treatment for Binge Eating Disorder is still missing and can help to elucidate this question. METHODS AND RESULTS: In an Internet-based cognitive-behavioral intervention, working alliance (WAI-S, mid n = 59; post n = 49) and eating disorder symptoms (EDE-Q, n = 49) as therapy outcome were assessed. A positive working alliance was reported by study participants. Working alliance had significant correlations with and EDE-Q-scales but not with binge eating episodes. CONCLUSIONS: Our study refers to the important role working alliance has for therapy outcome.

Internet-based interventions for eating disorders in adults: a systematic review.

BACKGROUND: This systematic review evaluates the efficacy of internet-based interventions for the treatment of different eating disorders in adults. METHOD: A search for peer reviewed journal articles detailing Randomised Control Trials (RCT) and Controlled Trials (CT) addressing participants with eating disorders aged at least 16 was completed in the electronic databases Web of Science, PsycInfo and PubMed. The quality of the included articles was assessed, results were reviewed and effect sizes and corresponding confidence intervals were calculated. RESULTS: Eight studies, including a total of N = 609 participants, fulfilled the selection criteria and were included. The majority of treatments applied in these studies were based on CBT principles. Six studies described guided self-help interventions that showed significant symptom reduction in terms of primary and secondary outcomes regarding eating behaviour and abstinence rates. These studies produced significant medium to high effect sizes both within and between the groups after utilisation of guided self-help programs or a self-help book backed up with supportive e-mails. The two remaining studies utilised a specific writing task or e-mail therapy that did not follow a structured treatment program. Here, no significant effects could be found. Treatment dropout rates ranged from 9% to 47.2%. Furthermore, reductions in other symptoms, for example depression and anxiety, and an increase in quality of life were found by four studies. CONCLUSIONS: Overall, the results support the value of internet-based interventions that use guided self-help to tackle eating disorders, but further research is needed due to the heterogeneity of the studies.